Surgical Considerations in the Competitive Athlete– Part 2 APRIL/MAY 2005 • PODIATRY MANAGEMENT www.podiatrym.com 203 the philosophy and physiology of athletic competition. In this seg- ment, Dr. McNerney discusses some common conditions found in ath- letes. Deviated, Subluxed or Dislocated MPJ’s and Hammertoes Pain in the lesser metatarsal-pha- langeal joints is commonly seen in ath- Continued on page 204 Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin- uing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $17.50 per topic) or 2) per year, for the special introductory rate of $109 (you save $66). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the near future, you may be able to submit via the Internet. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned cred- its. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 210. Other than those entities cur- rently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected]. Following this article, an answer sheet and full set of instructions are provided (p. 210).—Editor Continuing Medical Education Editor’s Note: This is a con- tinuation of the March CME in which Dr. McNerney discussed both By John E. McNerney, D.P.M. These unique patients must be evaluated differently than your typical patients. Goals and Objectives After reading this article the podiatric physician should be able to: 1) Define what a competitive or elite athlete is, and understand how he/she differs from the average podiatric patient, both physiologically and psychologically. 2) Be able to apply the 5 A’s of athletic medicine to their practice. 3) Be able to identify the demands of sport on the athlete, and understand how those demands may alter the surgi- cal outcome of certain procedures. 4) Identify some of the physiologic changes that occur in the elite or com- petitive athlete. 5) Understand the effects of extended detraining on competitive athletes. 6) Have a better understanding of the complexity of the athletic psyche and how it may affect surgical outcomes. 7) Recognize the pitfalls of normal podiatric surgical procedures on the elite athlete. 8) Be better able to diagnose certain podiatric conditions and choose proce- dures with better outcomes when sur- gery is required in competitive athletes. SPORTS PODIATRY SPORTS PODIATRY Getty Images/PhotoDisc
the philosophy and physiology ofathletic competition. In this seg-ment, Dr. McNerney discusses somecommon conditions found in ath-letes.
Deviated, Subluxed or DislocatedMPJ’s and Hammertoes
Pain in the lesser metatarsal-pha-langeal joints is commonly seen in ath-
Continued on page 204
Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin-uing Medical Education by the Council on Podiatric Medical Education.
You may enroll: 1) on a per issue basis (at $17.50 per topic) or 2) per year, for the special introductory rate of $109 (yousave $66). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the nearfuture, you may be able to submit via the Internet.
If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned cred-its. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test atno additional cost. A list of states currently honoring CPME approved credits is listed on pg. 210. Other than those entities cur-rently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable byany state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensurethe widest acceptance of this program possible.
This instructional CME program is designed to supplement, NOT replace, existing CME seminars. Thegoal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscriptsby noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: PodiatryManagement, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected].
Following this article, an answer sheet and full set of instructions are provided (p. 210).—Editor
Continuing
Medical Education
Editor’s Note: This is a con-t inuat ion of the March CME inwhich Dr. McNerney discussed both
By John E. McNerney, D.P.M.
These uniquepatients must be
evaluated differentlythan your typical
patients.
Goals and ObjectivesAfter reading this article the podiatricphysician should be able to:
1) Define what a competitive or eliteathlete is, and understand how he/shediffers from the average podiatric patient,both physiologically and psychologically.
2) Be able to apply the 5 A’s of athleticmedicine to their practice.
3) Be able to identify the demands ofsport on the athlete, and understandhow those demands may alter the surgi-cal outcome of certain procedures.
4) Identify some of the physiologicchanges that occur in the elite or com-petitive athlete.
5) Understand the effects of extendeddetraining on competitive athletes.
6) Have a better understanding of thecomplexity of the athletic psyche andhow it may affect surgical outcomes.
7) Recognize the pitfalls of normalpodiatric surgical procedures on the eliteathlete.
8) Be better able to diagnose certainpodiatric conditions and choose proce-dures with better outcomes when sur-gery is required in competitive athletes.
S P O R T S P O D I A T R YS P O R T S P O D I A T R Y
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of the cartilage at the metatarsal head.Two factors are then assessed. Did thesurgery release the deformity and restorenormal joint alignment, and is thereany damage to the cartilage of themetatarsal? If the MPJ remains deviated
when loaded, did not fully release or ifthe PIPJ is still hammered, a plantarplate release is performed. This allowsthe displaced flexor tendon and plantarplate to slide back under the metatarsalhead. If the MPJ remains deviated orcannot be fully reduced, some type ofosteotomy of the metatarsal head is per-formed. Where the joint is pristine, adistal metaphyseal osteotomy (Weil orHelal type), is performed.(31)
I prefer a biased “V” type osteotomy(more bone is removed on the lateralside to allow the metatarsal head to slidemedially under the phalangeal base), fix-ation is optional, but when needed Iprefer a single absorbable pin. (Figures3,4) When the joint is damaged orwhen the deformity precludes total re-duction, a partial metatarsal head andplantar condylectomy can be substitut-ed for the osteotomy.(29) Joint destructiveprocedures, like the metatarsal head re-section, can lead to telescoping of thetoe, loss of push-off, non-purchase ofthe toe or stress fractures of the adjacentmetatarsals. None of these problems
Figure 3: A pre-operative X-ray of a34 year old runner. Note the moder-ate to severe hallux valgus, the medi-al deviation of the 2nd metatarsalphalangeal joint (“V sign”) and the“tailors” bunion over the 5thmetatarsal. The major complaint waspain under the 2nd metatarsal. Therewas also significant callus over themedial aspect of the 1st MPJ and IPJalong with a circumscribed callus(IPK) under the 5th metatarsal head.
metatarsal neuroma, especially in ab-sence of the classically subjective com-plaints, when the deformity is in the2nd metatarsal and where the “V” signis present, is particularly disturbing. The“interspacectomy” performed is seldomsuccessful and often leads to greater painand deformity.(29, 30)
In early or predislocation of the less-er metatarsals, soft tissue procedures arecommonly suggested, but the vast arrayof procedures can be confusing. (30) Inlater stages, a combination of soft tissuerelease with osteotomies of themetatarsal and/or arthroplasty of thehammertoe are preferred. (30) The myriadof procedures proposed for this condi-tion attests to the fact that while manyprocedures are helpful, there is no clear-cut consensus. When one views the risk/benefit of many of these procedures inthe athlete, some approaches may beeliminated. Flexor transfers, proximalphalangeal base resections, syndactyly,joint implant and osteotomies of themidshaft or base of the metatarsal havelittle place in surgical correction of these
deformities in the athlete, due to ex-tended detraining time, morbidity, orfailure rates.
My approach to this condition is asimple step-wise plan. (29) Soft tissue re-lease is the first step. A full MPJ capsulo-tomy is combined with an extensortenotomy. This allows reduction of theMPJ extension and allows for inspection Continued on page 205
letes. The deformity may be trau-matically induced, can be a progres-
sive luxation due to idiopathic swellingin a joint, or may be associated with hal-lux valgus.(29, 30) Regardless of the etiology,a deviation, subluxation or dislocation oftoe on the MPJ, with possible hammer-toe, is accompanied by pain and swellingin the affected joint. (29,30) The classic “V”
sign (Winston Churchill sign) is oftenseen where adjacent toes deviate in oppo-site directions.(29) (Figures 1,2)
Conservative treatment of lessermetatarsal pain in athletes must startwith off-loading the metatarsal. “U”shaped cut-outs placed into padding,strapping, arch supports or orthotics andproper shoe gear selection are extremelysuccessful in off-loading the part andslowing the progression of the deformi-ty. (29) Oral anti-inflammatory medica-tion can augment the off-loading, butinjection of corticosteroid should bedone reluctantly. (30) When treated prop-erly with off-loading, proper shoe selec-tion, modification of activity and judi-cious use of medication, the symptomsof this disorder are commonly con-trolled. The angulation deformity andhammering of the toes may remain butare asymptomatic.(29, 30)
In rare cases when conservativetreatment is unsuccessful, surgery maybe necessary, but the selection of theproper procedure is crucial. Unfortu-nately, this disorder is often operated onprematurely or improperly because ofmisdiagnosis or poor understanding ofthe deformity. The diagnosis of inter-
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Figure 2: The same condition as be-fore seen on x-ray. Note that the 2ndtoe has drifted medially, the 2ndmetatarsophalangeal joint is sub-luxed, and there is an obvious gapbetween the 2nd and thirdmetatarsals (“V” sign”), indicativethat the pathology is in the 2nd MPJ.
Figure 1: Note the mild Hallux Valguswith the medial drift of the 2nd toeand obvious “V” sign between the2nd and third toes. This runner hadpain sub 2nd metatarsal on push offdue to pre-dislocation syndrome ofthe 2nd toe. This condition is oftenmisdiagnosed as a neuroma.
for diagnosis. (32) Commonly avulsion ofthe styloid process and stress fracturesaretreated benignly. It has been said thatany form of limited weight bearing orimmobilization is adequate to heal thesefractures; this has not been my experi-ence in athletes. (29) I prefer a short legnon-weight-bearing cast at leastuntil some bone callus is noted,usually 2-4 weeks. Then mobiliza-tion with aggressive rehabilitationcan be started. In all 5thmetatarsal fractures, non-union ordelayed union (no evidence ofhealing within 3 months of dis-covery) surgery is warranted. (33)
There is good evidence thatpulsed electromagneticfields andorthotics may be helpful to allowathletes to achieve earlier healingand faster ambulation.(29, 32, 33)
Jones FractureTreatment of a Jones fracture
in the elite athlete is a hotly debat-ed topic with some authors suggestingthat surgery is always required. (34) Surgi-cal technique is also a topic of debate,but it would appear that most 5thmetatarsal base fractures are best treatedby intra-medullary screw fixation (Figure7).(29, 32-34) Bone grafting has been suggest-ed, but the prolonged healing times donot usually warrant this more extremeapproach. (33) Most experts agree that a
should preclude using this procedure inthe athlete when necessary since therisk/ benefit is almost always positive.
When hammertoe surgery is re-quired either as a combined or isolatedprocedure, I find arthroplasty of theproximal interphalangeal joint to be theprocedure of choice.(29) I try not to fixatethe surgery because of the increasedmorbidity and minimal benefit in mostathletes. (Figure 5) While it is a fact thatPIPJ fusion produces a more stable toejoint and seldom requires future surgery,the higher morbidity rates, high rate offusion failure, and longer post-operativecourse seldom warrant this choice inelite athletes.
Inversion sprain or direct traumacan fracture at the base of the 5thmetatarsal in athletes. (29, 32) Stress frac-ture, avulsion fracture of the styloidprocess, or fracture of the proximal5th metatarsal base in the diaphysealarea 1.5 cm. distal to the styloid pro-cess (Jones’ fracture) are common. (32)
Fractures to this area, especially theJones’ fracture, have the reputation ofbeing difficult or impossible to heal.(29) In reality, acute Jones’ fracturescommonly heal in 6-8 weeks whentreated with early immobilization in ashort leg non-weight-bearing cast. (33)
The most important factor in treat-ment of Jones’ fracture is early recogni-tion, and is aided by a high “index ofsuspicion”.(29, 33) When not treated in theacute stage, a Jones’ fracture can result inpoor healing. Torg states that the pres-ence of intramedullary sclerosis in thediaphyseal area of the metatarsal is anominous sign. (33) It is the hallmark ofchronic irritation and the result of de-layed or non-union base of 5th fracture.(Figure 6) It is this chronic type of Jones’fracture that is difficult to heal and oftenrequires surgery or lengthy periods of de-training. Stress fracture and avulsionfracture of the 5th metatarsal seldom re-quire surgery as long as they are recog-nized early and treated aggressively. (29)
Diagnosis is usually facilitated by a ra-diograph, the mechanism of injury, orpain and limping.
Stress FracturesStress fractures of the 5th metatarsal
are more difficult to uncover with radio-graphs and usually require a bone scan
Athletic Surgery... non-weight-bearing proto-col is needed post-operativelyfor about 6-8 weeks (or until someevidence of bone callus is seen), fol-lowed by aggressive rehabilitation.(29)
Re-fracture through the area iscommon especially when fracturesare treated non-surgically, but majorsequella to all types of surgical treat-ment are also common.
Os Trigonum Surgery and ChipFractures
Forced movement of the foot orankle (especially plantarflexion) can leadto joint injury or chip fractures. Injury tothe os trigonum, posterior ankle im-pingement or fracture of Stieda’s processof the talus due to extreme plantarflex-ion (called “nutcracker” syndrome) iscommon in dancers who spend longperiods of time “en pointe”(35) Often thisgroup of injuries to the posterior ankle ismisdiagnosed as Achilles’ tendonitis, soa “high index of suspicion” is helpful indifferentiating different disorders.
Most cases of os trigonum syn-drome respond to conservative treat-ment, including rest, orthotics, medica-tion (NSAID’s, oral or injectable steroid)and aggressive therapy with physicalmodalities. In those cases where non-surgical treatment is unsuccessful, onemust suspect fracture of the os trigon-um. MRI is the best diagnostic tool, be-
cause radiographs and bone scans oftenfail to distinguish between flexor hallu-cis longus or Achilles’ tendonitis, posteri-or impingement, accessory ossicles orfracture.(36)
All symptomatic chip fractures ofthe foot, including os trigonum frac-tures, require excision when symptomspersist and prevent athletic competition.
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Figure 4: The same runner is about 5months post-operatively. Note thatthe 2nd MPJ subluxation is totallycorrected with a non-fixated offset“V” osteotomy. A closing wedge uti-lizing tangential 28 g. monofilamentwire was used to correct the“bunion” and Hohman slide osteoto-my with absorbable pin fixation wasused to correct the “tailor’s” bunionof the 5th metatarsal.
Figure 5: An intra-operative view of a hammertoearthroplasty. The patient had a consistent painfulheloma durum with underlying bursitis of the 3rdtoe. Correction was achieved by removal of thehead of the proximal phalanx. The extensor ten-don is shown being sutured back in place.
In comparative studies, control ofabnormal biomechanics with arch sup-ports or orthotics yielded the best singu-lar results. (38) Other conservative treat-ment modalities can include: stretching,NSAID’s, cortisone injection, change ofshoe-gear, night splints, physical thera-py and immobilization.
Surgery should never be the first re-sponse to heel pain in the elite athlete,and should only be considered when allother causes of heel pain are ruled out,and all other methods of treatment havebeen exhausted. This process often takesat least three to six months to run itscourse. Most athletes can train at lowerlevels during the healing process.
Despite claims to the contrary, mostsurgical approaches yield similar results,and all have a variable long term prog-nosis. (37) Newer treatment modes likeendoscopic plantar fasciotomy (EPF)and extra-corporeal shock wave therapy(ESW) have been touted for treatment ofheel pain in athletes.(39, 40) Although fewlong-term studies exist for the use of EPFor ESW on elite athletes, their value maylie in their less invasive nature.
Major and Minor Tendon SurgeryThe tendons of the lower leg, foot
and ankle are often involved in athleticinjury.(41) Injury at the origin, insertion,
or the course of the anterior or posteriortibial or peroneal tendons is commonlytermed “shin splint” syndrome and isgraded on a 0-4 scale based on intensi-ty.(41) “Shin splints,” along with injury to
the Achilles tendon (tendinosis, partialor total tear), are the most commonlyinjured major tendons of the lowerleg.(41, 42) Treatment with rest, ice, physicaltherapy, NSAID’s stretching, shoe gearchange and arch support or orthotics,and aggressive therapy is successful in al-most all cases.
It is rare that surgery is needed totreat foot or lower leg tendon injuries.An exception to the rule might be a ten-don rupture. In this instance, delay insurgical treatment might have a deleteri-ous effect, and early intervention maybe warranted. For other injuries wherenon-surgical treatment has not resolvedthe problem in a reasonable time period(3-6 months), surgery may be consid-ered if the athlete cannot compete ortrain at a normal level.
Paratenon stripping (of the Achilles’),fasciotomy of the lower leg (for compart-ment syndrome), removal of degeneratedtendon, and/or repair of ruptured ten-dons can be successful in selected cases.(42)
Surgery in the competitive athlete shouldbe avoided in most other cases because ofthe high complication rates, re-injury,and the need for extensive detraining.The last problem is that the post-opera-tive strength of a tendon that has beenoperated on generally drops one gradefrom its pre-operative level.
While seldom indicated, minortendon surgery at the metatarsal or toelevel when required, heals rapidly, andwithout incident, and in most cases,allows training almost immediately.
Superficial Soft Tissue, Neuromaor Nail Surgery
Skin, soft tissue and nail injuries arecommon in the athlete due to the envi-ronment of the foot in sports shoes andthe trauma of sport itself.(14, 29) Most ofthese injuries require only ameliorativetreatment such as shoe gear change,padding, strapping, shock attenuationor manual debridement. (14, 29)
When nails become thickened,fungal or ingrown, regular debride-ment is essential to control pain. Thesame is true of calluses, corns or in-tractable plantar keratomas, or verru-ca plantaris. (29) On occasion, theseproblems are so severe that they maywarrant more radical intervention.
Ingrown or Thickened NailsRecurrent ingrown or thickened
nails might sometimes require surgicalremoval with or without ablation of the
The orientation of most chip frac-tures in the foot responds well to
simple excision. The post-operativecourse is speeded along by aggressivetherapy. Excision of the os trigonum be-cause of its placement near the posteriorsub-talar joint requires longer rehabilita-tion and more care in excision, and hasa fairly high rate of sequella. I prefer alateral approach to remove os trigonal
fractures. The approach is more difficult,but there are fewer anatomical structuresthat need to be avoided, and rehabilita-tion can be started earlier.
Plantar Fasciitis (Heel Pain Syndrome)It has been said that “not every heel
pain is a heel spur and not every heelspur causes heel pain.” (37) The triad in-jury of plantar fascia, calcaneodynia(heel pain due to bursitis, periostitis ormyositis) with Achilles tendonitis iscommonly referred to as “heel pain syn-drome.” (14) The etiology is almost exclu-sively biomechanical, although nerveentrapment, arthridities, or fracture mayoccasionally be a cause of the pain. (14, 38)
Foot radiographs, bone scans or MRImay show an infero-medial spur, or inrare cases a stress fracture. (Figure11)(14)
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Figure 7: The same patient about twomonths later after surgical fixation ofthe fracture with an intramedullaryscrew. He was kept strictly non-weight-bearing until just after this x-ray. He was allowed to return to lightpractice in 10 weeks and was playingcompetitively in four months.
Figure 6: A 19 year old basketballplayer with a Jones’ fracture of thebase of the 5th metatarsal. His chiefcomplaint was mild pain for over oneyear, but he played and practicedcompetitively throughout the year.Note the fracture line with sclerosisboth above and below the fractureline and through the medullarycanal. This type of intramedullarysclerosis is an ominous sign for frac-ture healing.
nosed and improperly operated on es-pecially when it involves the secondand third digits.(30)
Conservative care using a metatarsaldispersion pad, orthotics, shoe gear alter-ation, NSAID’s and cortisone injectionsare said to be successful in 20-30% of the
population. (43) I feel this isoverly optimistic in thecompetitive athlete. Thestatistics notwithstanding,conservative treatmentshould always be attempt-ed. This is one case when,where properly diag-nosed, it may be best toperform surgery soonerthan later.(29)
I prefer a dorsal inci-sion and early weight-bearing. Return to sportcan be rapid since inmany cases the pain theathlete has post-opera-tively is equal to or lessthan the pre-operativelevels. Still one must erron the side of caution
until the athlete can push off withoutguarding the surgical area.
Sports Medicine PhilosophyIn the late 1970’s to early 1980’s
the post-injury and post-operative pro-tocols for many athletic injuries (knee,ankle, 1st MPJ and even fracture man-agement) were drastically changed bythe sports medicine philosophy. Longperiods of complete immobilizationgave way to early controlled mobiliza-tion with protected weight bearing.
offending nail plate. (29) (Figure 9) Whenablation of the nail is necessary, I preferthe phenol-alcohol type of nail ablationto the more aggressive surgical excisionsince it heals rapidly with minimal se-
quellae and the athlete can usually com-pete without interruption.
Warts, Corns, CallusesWhen warts, corns, and calluses
are recalcitrant to treatment, the useof salicylic acid preparations com-bined with local debridement is oftenhelpful.(29) When this fails, I prefer toenucleate and saucerize warts in lieuof other more radical methods of sur-gery (including laser treatment).(29)
The exception might be in caseswhere the warts are of the mosaic orcompound type and cover large sur-face areas. In this case, where othermethods of treatment fail, laser maybe the better choice to allow the ath-lete to compete faster.
There are few times when a compet-itive athlete requires surgery for an IPKor corn. When needed, I prefer a simplehammertoe arthroplasty for corns, and anon-fixated “V” osteotomy for IPK’s.Both procedures heal rapidly and I havefound few sequella in either.(29)
Morton’s NeuromaThe “Morton’s” or inter-digital pe-
ripheral neuroma is a common disor-der in competitive athletes (29). It usu-ally presents with pain and/or numb-ness radiating to the lesser toes, espe-cially the third and fourth digits.(29)
This disorder is commonly misdiag-
Athletic Surgery... Active joint motion andweight bearing were startedearlier and more aggressively.(6)
Continuous passive motion,cryotherapy, electrogalvanic stimula-tion, anti-inflammatories, and othermodalities to reduce pain and swellingwere used aggressively and early in re-habilitation. The philosophy has afour-pronged attack.(6) The first stage isrelative rest (activity to the point ofdiscomfort), ice and compression, andprotected weight-bearing.
In 1-3 weeks, the second stage (in-creased mobilization with active rangeof motion) starts, allows healing withminimal scarring and shortening of softtissues. In stage three, as tissue healingincreases, active stretching, more aggres-sive range of motion and non-protectedweight-bearing are started. The last stageis return to sport and should occur in 6-8 weeks or less in most cases.
The adaptation of this philosophyhas enabled those treating athletes toshorten periods of detraining withoutendangering post-operative results,and improving function over theolder methods.
Recently, a push toward the Swiss orA-O concepts of fracture fixation andnon-weight bearing has been in vogue.This regressive philosophy of long peri-ods of non-weight-bearing has never fullypenetrated the sports medicine world.
As time has progressed, the litera-ture has shown over and over thatearly protected weight-bearing, rapidmobilization and early return to activ-ity produced better, long-term resultspost-operatively.
ConclusionTreatment of competitive athletes
presents a unique challenge to thepodiatric surgeon. In order to suc-ceed, one needs to account for thedifferences between the normal pod-iatric surgery patient and the moreathletic ones. In most cases, surgeryshould be the last option.
In those athletes where no other op-tion exists, or where conservative treat-ment has failed and surgery is required,some simple rules will help keep the ath-lete safe. First, immobilize as little as pos-sible—every week of detraining requirestwo weeks of reconditioning.(44) Earlyand rapid mobilization is the best post-operative protocol in almost every sur-gery.(6, 44)
Try to avoid those surgeries whereContinued on page 208
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Figure 8: A lateral X-ray shows evidence of an infra-cal-caneal and retro-calcaneal spur in a 26 year old dancer,who was complaining of pain in her heel while dancing.She was treated non-surgically (via orthotics and aggres-sive calf stretching) and returned to full activity within 4weeks. The presence or absence of spurs in heel pain syn-drome has no bearing on clinical course. One must remem-ber the calf muscle and Achilles’ tendon are part of thesyndrome (as shown here by the retro-calcaneal spur).
Figure 9: A 41 year old tennis player pre-sented with pain in the hallux for about8 weeks. He had tried hot soaks and hisfamily physician placed him on Keflex500mg. taken twice daily for about twoweeks prior to his visit, with no resolu-tion. In the office, under local anesthesia(Xylocaine 2% plain, 3cc. as a toe block)the offending portions of nail were ex-cised (both medially and laterally). Thepatient was back playing tennis within 4days of the procedure in a loosely-fittedtennis shoe.
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23) Austin, DW, Leventen, EO: A new os-teotomy for hallux valgus: a horizontally direct-ed “V” displacement osteotomy of themetatarsal head for hallux valgus and primusvarus. Clin. Orthop. 157, p. 25-30, 1981.
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25) Brunetti, VA, Trepal, MJ, Jules, KA: Fixa-tion of the Austin osteotomy with bioabsorbablepins. J. Foot Surgery. 30:1, p. 56-65, 1991.
26) Viehe, R. Haupt, JD, Heaslet, MW, Wal-ston, S.: Complications of screw-fixated chevronosteotomies for the correction of hallux abductovalgus. JAPMA. 93:6, p. 499-502, 2003.
27) Rodeo, SA, O’Brien.S., Warren, RF, et.al:Turf-toe: an analysis of meta-tarsophalangeal
joint range of motion is likelyto be compromised. Even small
range of motion losses in the eliteathlete can have a profound effect onmechanics and lead to higher post-operative complication rates.(3,6,44)
Avoid implanted materials asmuch as possible. Screws, wires, pins,plastics or other embedded materialsleft in bone or soft tissues can causeincreased scar tissue, bone stress risersor re-absorption and lead to increasedstress fracture rates.(44) When bone fix-ation is required, removable or dis-solvable materials are preferred inmost cases. 25,26)
Make the surgery as “technically”perfect as possible. (2) Avoid poorlyplaced incisions, underscore tissue aslittle as possible and choose sutureand other implanted material careful-ly to avoid abnormal scarring.(44)
Remember that the elite athletehas a complex psychology. Long peri-ods of rest, the stress of surgery andanxiety, both pre-and post-operative-ly, can cause a perfect procedure to goimperfectly. Informed consent,knowledge regarding the post-opera-tive course and reasonable surgical ex-pectations are crucial to avoid prob-lems. Cross-training, aggressive post-operative rehabilitation and emotion-al support are as essential as the sur-gery itself to achieve good results. (6,11)
When the above material is under-stood, surgery on the competitive ath-lete can be rewarding to both the sur-geon and the athlete. When surgeryfails it is most often due to failure injudgment, and not technique. Thesurgeon who understands that theproper outlook results in the properoutcome is seldom disappointed. ■
31) Trnka, HJ, Muhlbauer, M, Zetti, R.:Comparison of the Weil and Helal osteotomiesfor the treatment of metatarsalgia secondary todislocation of the lesser metatarsophalangealjoints. Foot & Ankle. 20, p. 72, 1999.
32) Landorf, KB: Clarifying proximal dia-physeal fifth metatarsal fractures: the acute versesthe stress fracture. JAPMA. 89, p. 389, 1999.
33) Torg, JS., et. al.: Fractures of the base ofthe fifth metatarsal distal to the tuberosity. JBJS.66, p. 209, 1984.
34) DeLee, JC, Evans, JP, Julian, J.: Stress frac-tures of the 5th metatarsal. Am. J Sports Medi-cine. 5, p. 349, 1983.
36) Wakeley, CJ, Johnson, DP, Watt, I.: Thevalue of MR imaging in the diagnosis of ostrigonum syndrome. Skelatal Radiol., 25, p. 133,1996.
37) Contompasis, JP: Surgical treatment ofcalcaneal spurs: a three year post surgical study.JAPA. 64., p. 987, 1974.
38) Lynch, M, Goforth, P, Martin, J. et.al:Conservative treatment of plantar fasciitis.JAPMA. 88:8, p. 375-380, 1998.
39) Barrett, SL, O’Malley, R.: Plantar fasciitisand other causes of heel pain. Am. Family Physi-cian. 59:8, p. 2200-2206, 1999.
40) Wang, CJ, Chen, HS, Huang, TW.:Shockwave therapy for patients with plantarfasciitis: a one year study. Foot & Ankle Int., 23:3,p. 204-207, 2002.
41) Bowyer, BL, McKeag, DB, McNerney,JE.: When a beginning runner overdoes it. Pa-tient Care. April, p. 54, 1994.
42) Torg, JS, Pavlov, H., Torg, E.: Overuse in-juries in sport: the foot. Clin. Sports Med., 6, p.291, 1987.
43) Gaynor, R., Hake, D., Spinner, S., et.al.: Acomparative analysis of conservative verses surgi-cal treatment of Morton’s neuroma. JAPA. 79, p.27, 1980.
44) Croce, P., Gregg, JR: Keeping fit wheninjured. Clin. Sports
Dr. McNerney isteam podiatristto the New Jer-sey Nets Basket-ball Club and toKean University.He serves as aconsultant pod-iatrist to theNew York Foot-ball Giants andthe New Jersey Devils Hockey Club. Addi-tionally, he is podiatric coordinator forthe New York Marathon. Dr. McNerneyis in private practice is Westwood, NJ.
screw is a preferred method ofsurgical treatmentD) bone grafting shortens thehealing time
6) All of the following describe in-juries to the os trigonum except:
A) “nutcracker syndrome”B) posterior impingementC) Freiberg’s infractionD) Stieda’s process fracture
7) The best diagnostic tool for in-juries to the os trigonum is:
A) bone scanB) X-rayC) complete blood count,blood uric acid and sedimenta-tion rateD) MRI
8) The following is most true re-garding removal of os trigonalfractures of the foot in an elite ath-lete:
A) rehabilitation is rapid be-cause of the fracture’s place-mentB) sequellae to fracture or frac-ture removal is rareC) a lateral surgical approach ismore difficult but preferredD) physical therapy has littleeffect on the post-operativecourse
9) “Heel pain syndrome” includesall of the below except:
10) Which is not true about “heelpain syndrome” in competitiveathletes:
A) orthotics are effectiveB) surgery is very often neces-saryC) stretching often exacerbatesthe painD) cortisone injection is some-times an effective treatment
1) 5th metatarsal fracture in thecompetitive athlete can be:
A) a stress fractureB) caused by an inversionsprainC) caused by direct traumaD) all of the above
2) Which does not belong in thegroup below:
A) fracture 1.5 cm. distal to the5th metatarsal styloid processB) Jones’ fractureC) angular midshaft 5thmetatarsal fractureD) proximal 5th metatarsalbase fracture
3) According to Torg, the “hall-mark” chronic bone irritation thatis indicative of delayed or non-union in Jones’ fracture is:
A) intramedullary sclerosisB) a fracture line 1.5 cm. distalto the 5th metatarsal styloidprocess.C) a gap of more than 3 mm.across the fracture siteD) peroneus brevis interposi-tion in the fracture site
4) Which of the following is mostgenerally a true statement for eliteathletes:
A) all avulsion fractures heal aslong as you limit weight-bearingB) avulsion fractures of the 5thmetatarsal heal faster thanJones’ fracturesC) avulsion fractures of the 5thmetatarsal occur 1.5 cm. distalto the styloid process.D) a bone scan is generally re-quired to uncover a 5thmetatarsal avulsion fracture.
5) The following statements aboutJones’ fractures of the 5thmetatarsal in the competitive ath-lete are all true except:
A) surgery is always necessaryB) a “high index of suspicion”is helpful in diagnosisC) fixation by intramedullary
11) When doing surgery for heelpain in the elite athlete:
A) it should be a first line treat-ment mode since conservativetreatment is seldom effectiveand we can return the athleteto sport soonerB) extracorporeal shock wavetherapy is preferredC) endoscopic plantar fascioto-my yields the best long-termresultsD) most surgical approachesyield similar long-term results
12) The term “shin splints” canrefer to all the below except:
A) a ruptured Achilles’ tendonB) injury to the posterior tibialtendonC) pain along the course of theanterior tibial tendonD) peroneal myositis or tendinitis
13) The most common reason forearly surgical intervention to treatmajor foot or lower leg tendon in-jury in the competitive athlete is:
14) Calluses, corns and nail injuriesin the competitive athlete mostoften require only:
A) ameliorative treatmentB) surgical correctionC) change of shoe gearD) rest, ice, compression andelevation
15) Morton’s neuroma in the com-petitive athlete:
A) is most often associatedwith the “V” sign in lesser toesB) responds to cortisone injec-tions in most casesC) is different from an interdig-ital neuromaD) often requires surgery
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Continued on page 210
210 PODIATRY MANAGEMENT • APRIL/MAY 2005
16) Plantar warts in an elite athlete:A) are easily cured by debridementB) are often recalcitrant to treatmentC) should never be treated with salicylic acidpreparationsD) should be treated by laser surgical treat-ment as quickly as possible
17) Rehabilitation according to the philosophyof sports medicine requires:
A) casts and non-weight bearingB) strictly defined range of motion limits andwith elimination of stretchingC) change of sport and surgery to correctthe deformityD) controlled mobilization, active joint mo-tion and protected weight-bearing
18) According to sports medicine philosophy,the primary goal in treating the competitiveathlete is:
A) a faster and safer return to sport.B) the use of the newest technologyC) prescribing a good cross training programD) early and aggressive surgery
19) All of the following apply to surgery on thecompetitive athletes except:
A) immobilize as little as possibleB) try to avoid surgery when joint ranges ofmotion may be compromisedC) use screws, pins, wires and implants asoften as possibleD) accept that incision placement, tissue un-derscoring and suture material selection canaffect scar formation.
20) Which statement is most true regardingfoot and ankle surgery in the elite athlete:
A) even when the surgery is less than per-fect, increased rest and immobilization helpto avoid problems.B) the less the athlete knows about the sur-gery, the less anxiety and the easier the postoperative courseC) perfecting your surgical technique is themost important factor in preventing surgicalfailures.D) aggressive physical therapy, emotionalsupport and judicious use of surgery are thekey factors in obtaining a good surgical result.
E X A M I N A T I O N
(cont’d)
See answer sheet on page 211.
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